Article Impact Level: HIGH
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Summary of New England Journal of Medicine, 383(14), 1383–1384. https://doi.org/10.1056/NEJMe2027180
European Heart Journal, 43(40), 4127–4144. https://doi.org/10.1093/eurheartj/ehac471
New England Journal of Medicine, 383(14), 1305–1316. https://doi.org/10.1056/NEJMoa2019422
European Heart Journal, 43(40), 4145–4147. https://doi.org/10.1093/eurheartj/ehac490
Circulation, 144(11), 845–858. https://doi.org/10.1161/CIRCULATIONAHA.121.056323
European Heart Journal, 43(12), 1219–1230. https://doi.org/10.1093/eurheartj/ehab593
Dr. Lars Eckardt et al

Points

• The key cumulative outcome regarding cardiovascular mortality, and stroke, showed significant declines. 
• Early pulse stabilization treatment appears more beneficial when sinus rhythm is present at 12 months.
• Among individuals with currently found Atrial Fibrillation and coexisting cardiovascular problems, the EAST-AFNET 4 study demonstrated that a rhythm-control technique is more effective than conventional therapy in promoting cardiac outcomes at 5 years.

Summary

The trial’s objective was to compare a rhythm-control method to standard therapy, which in most cases involved rate control for participants diagnosed with atrial fibrillation.

In a randomized controlled trial, patients with an Atrial Fibrillation diagnosis were assigned to two groups; one was a rhythm control group carrying 1395 participants, and the other was a standard treatment group carrying around 1394. Antiarrhythmic medication or AF ablation, as well as the early initiation of defibrillation for continued Atrial Fibrillation, was necessary for early rhythm control. Rate control therapy without rhythm control was used to manage standard treatment.

Inclusion criteria were based on a previous transient ischemic attack or stroke and early Atrial Fibrillation as those diagnosed within a year and over seventy-five years. The other requirements were age above sixty-five, female gender, having heart failure, high blood pressure, diabetes, significant cardiomyopathy, severe renal disease, and left ventricular hypertrophy with diastolic septal wall width greater than 15 mm. Compared to standard care for the duration of the follow-up, sinus rhythm at twelve months accounted for 80% of the therapeutic impact of early rhythm control therapy.

According to the findings of this significant experiment, rhythm-control strategies are preferable to standard therapy (which, in most cases, involves rate control) in terms of optimizing Cardiovascular endpoints at 5 years among individuals who have just been diagnosed with Atrial Fibrillation and concurrent Cardiovascular problems. Regardless of symptom state, results were consistent in the subset of heart failure patients.

Results from studies like CABANA-AF, AFFIRM, and RACE are not the same as those from this experiment. The sample participating in EAST-AFNET 4 is different from the other studies in that it has more recently developed Atrial Fibrillation within the past 12 months. In the present trial, there came up a comparatively high rate of AF ablation at 8% at enrolment and 20% of the respondents after 5 years.

Links to the articles:
https://academic.oup.com/eurheartj/article/43/40/4127/6675568
https://academic.oup.com/eurheartj/article/43/40/4145/6677265
https://academic.oup.com/eurheartj/article/43/12/1219/6358078
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.121.056323
https://www.nejm.org/doi/full/10.1056/NEJMoa2019422
https://www.nejm.org/doi/full/10.1056/NEJMe2027180

References

Bunch, T. J., & Steinberg, B. A. (2020). Revisiting rate versus rhythm control in atrial fibrillation—Timing matters. New England Journal of Medicine, 383(14), 1383–1384. https://doi.org/10.1056/NEJMe2027180
Eckardt, L., Sehner, S., Suling, A., Borof, K., Breithardt, G., Crijns, H., Goette, A., Wegscheider, K., Zapf, A., Camm, J., Metzner, A., & Kirchhof, P. (2022). Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: The EAST-AFNET 4 trial. European Heart Journal, 43(40), 4127–4144. https://doi.org/10.1093/eurheartj/ehac471
Kirchhof, P., Camm, A. J., Goette, A., Brandes, A., Eckardt, L., Elvan, A., Fetsch, T., van Gelder, I. C., Haase, D., Haegeli, L. M., Hamann, F., Heidbüchel, H., Hindricks, G., Kautzner, J., Kuck, K.-H., Mont, L., Ng, G. A., Rekosz, J., Schoen, N., … Breithardt, G. (2020). Early rhythm-control therapy in patients with atrial fibrillation. New England Journal of Medicine, 383(14), 1305–1316. https://doi.org/10.1056/NEJMoa2019422
Linz, D., & McIntyre, W. F. (2022). Sinus rhythm: The sine qua non for rhythm control? European Heart Journal, 43(40), 4145–4147. https://doi.org/10.1093/eurheartj/ehac490
Rillig, A., Magnussen, C., Ozga, A.-K., Suling, A., Brandes, A., Breithardt, G., Camm, A. J., Crijns, H. J. G. M., Eckardt, L., Elvan, A., Goette, A., Gulizia, M., Haegeli, L., Heidbuchel, H., Kuck, K.-H., Ng, A., Szumowski, L., van Gelder, I., Wegscheider, K., & Kirchhof, P. (2021). Early rhythm control therapy in patients with atrial fibrillation and heart failure. Circulation, 144(11), 845–858. https://doi.org/10.1161/CIRCULATIONAHA.121.056323
Willems, S., Borof, K., Brandes, A., Breithardt, G., Camm, A. J., Crijns, H. J. G. M., Eckardt, L., Gessler, N., Goette, A., Haegeli, L. M., Heidbuchel, H., Kautzner, J., Ng, G. A., Schnabel, R. B., Suling, A., Szumowski, L., Themistoclakis, S., Vardas, P., van Gelder, I. C., … Kirchhof, P. (2022). Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: The EAST-AFNET 4 trial. European Heart Journal, 43(12), 1219–1230. https://doi.org/10.1093/eurheartj/ehab593